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Obsolete Policy |
MAGI-Based Groups
In the MAGI-based methodology, determine the best estimate of each source of income a client expects to receive during the certification period.
Income may be averaged, anticipated, or annualized depending on the type of income, the history of receiving it, or expected future changes.
If a client receives stable, ongoing income, prorate the expected amount over the 12 month certification period to arrive at a monthly amount.
If the client will be paid monthly, bi-monthly, every week or every other week, determine the average income to be received each pay period.
Multiply the average by the number of pay periods in the certification period.
Then divide the total by 12 months to arrive at a monthly amount.
If a client will start to receive income from a new source in the application month, in the month after the application month, or in the first month of the new certification period after a review, determine the total amount expected to be received during the certification period.
If the client will be paid monthly, bi-monthly, every week or every other week, determine the average income to be received each pay period.
Multiply the average by the number of pay periods remaining in the certification period based on when the first check is received.
Then divide the total by 12 months to arrive at a monthly amount.
Example- James applied on March 31 for himself and his family for benefits to start in March. He just started a job the same day that he applied. He is paid every two weeks on Fridays. He will receive his first check on April 25th. He works 40 hrs/wk, earning $11.00/hr. He will receive 23 checks in the certification period.
Best estimate of income = $880 x 23 = $20,240/12 = $1,686.67/month
Monthly countable new income = $1,686.67
If a client has terminated income that will be received during the certification period, determine the total expected terminated income and divide by 12 months to arrive at the monthly average amount to be received during the certification period.
Example- John has been laid off from his employment. He says he can't afford his COBRA coverage and wants to see if he can qualify his family for Medicaid. His company gave him a severance check for $5,000, and he received only one pay check of $1,500 in the application month, which is his last check. There is no other income.
Best estimate of income = $6,500/12 = $541.67
Monthly countable terminated income = $541.67
John's HH size is 3 and so he qualifies for PCR coverage. His children qualify for Child Medicaid.
If a client expects to receive temporary, seasonal, contract or other infrequent income, prorate the income over the certification period.
When prorating temporary, seasonal or infrequent income, total the amount expected to be received during the certification period and divide it by 12 to determine the monthly amount.
Example (seasonal) - For the past 5 years, John has worked as a ski instructor for 6 months of the year at $1000/month. He also works for a landscaping company during the other 6 months and earns $2000/month wages.
Best estimate Ski Instructor = 6 months x $1000/month = $6000/12 months = $500/month
Best estimate Landscaping = 6 months x $2000/month = $12,000/12 months = $1000/month
Total countable income: $500 + $1000 = $1500/month
Example (temporary) - Jack was laid off and is now receiving unemployment. His weekly checks are $350 and he has 15 weeks of unemployment remaining as of the first day of the application month. Since this income will end, prorate it over the certification period. This will factor in the zero income months. Add the monthly amount to any other income the individual or household has.
Best estimate Unemployment = $350/week x 15 weeks = $5250/12 months = $437.50/month
Total countable Unemployment income $437.50/month.
If a client is self-employed, determine the expected annual income to be received from the self-employment work. Divide the annual amount by 12 to determine the average monthly income.
Use the total monthly amount of income expected to be received to conduct a reasonable compatibility test and to determine eligibility for the certification period.
Reasonable compatibility: Determine if the reported income is reasonably compatible with electronic verification sources. The reasonable compatibility test compares the best estimate of countable income that the agency derives based on the client's statement with the best estimate of countable income derived from available electronic income sources. Compare those amounts against the income limit for the applicable MAGI-based coverage group. Deduct any allowed expenses from both the client statement of income and the electronic source of income before doing the reasonable compatibility test.
If both the client's statement and the electronic income match are at or below the income limit for the applicable MAGI-based coverage group, the individual is eligible.
If both the client statement and the electronic income match are above the income limit for the applicable MAGI-based coverage group, the individual is ineligible for the MAGI-based coverage group. Determine eligibility for any other medical assistance program.
If one income amount is above and one income amount is below the income limit, request additional verification from the client. Sec. 731.
For MAGI-based coverage groups, allow the 5% of FPL disregard when determining eligibility.
Non-MAGI-Based Family, Child and Pregnant Women Groups (i.e., Medically Needy)
Use prospective budgeting for non-MAGI-based coverage groups to determine the monthly income. Budget based on the client's current circumstances.
The household size may change (in some cases) and whose income is counted is different between MAGI-based and non-MAGI-based groups. The countable income may be different for the non-MAGI-based groups.
Income may be averaged, anticipated, or annualized depending on the type of income and the history of receiving it.
Determine the best estimate of expected current income to determine eligibility and the amount of the monthly spenddown, if applicable. Do not count income that is expected in future months, but is not being received in the current month. Complete a new best estimate when that income starts being received.
Terminated income: If income terminates in the application month, do not count that income for future months.
If a client will receive income from a terminated source in the application month or in the first month of the new certification period after a review, count the actual amount received in that month.
Do not factor terminated income.
Example: Zane applies in June for Medicaid for his family of 4. He reports that his job ended and he will get his last check in June. His total income in June from the terminated source will be $1000. His wife works half-time and is paid a salary of $1000/month. The annual income is $1000 + ($1000 *12) or $13,000. The monthly income for MAGI-based groups is $1083.33. The parents are not eligible for MAGI-based PCR Medicaid. Complete a best estimate for the medically needy program based on the income they will actually receive in June. Their spenddown in June would be based on the actual income of $2000. In July forward, the spenddown will be based on the wife's $1000 monthly income after applying allowed income disregards.
If a client is working a seasonal job at the time of application or renewal, determine the best estimate of income the client receives. Factor income received weekly or every other week to arrive at a monthly amount. Count this income for the number of months the client will work at this seasonal job. If the client expects to start a seasonal job sometime during the certification period, do a new best estimate at the time the seasonal job starts.
If a client receives income infrequently such as from contract work, commissioned employees, self-employed individuals, or other similar employment, determine the monthly average income based on the client's income history. Such income may be annualized or counted over the period of months it is intended to cover.
If income begins in the application or renewal month, count the actual expected amount of income from that source for the household member. Factor new income only if the client receives the full number of paychecks for the month.
Do not factor new income in months when the client does not receive the full number of paychecks for that month.
If the income received in the application month is not reflective of income that will be received in future months, a second best estimate may be required for the ongoing months.
Example 1: Sue applies on June 15th for herself and her two children. She reports she just started a new job. In June, she will only receive 1 check of $360. In future months, she will be paid every two weeks, and the checks will be $720 each. Her expected annual income will be $16,920, $1410 monthly. She is not eligible for the MAGI-based PCR program. Her two children are eligible for Child Medicaid. However, in the application month, Sue is eligible for Family Medically Needy because her actual income of $360 is below the $583 income limit. She will have no spenddown. Her spenddown in the ongoing months would be $875. ($720*2.15 = $1548-$90-$583 = $875)
Example 2: Same situation as in Example 1. Worker finds no electronic source of income for the retroactive period and reviews eligibility for the retroactive months. Sue reports no income in the retroactive period, and meets all other eligibility criteria. The worker approves her for MAGI-based PCR in those months, because we only count actual income. Since she qualifies for PCR in the retroactive period, she qualifies for Transitional Medicaid when her income increases in June. Begin Transitional Medicaid in June.
Temporary income: When income will be received for a set time period during the certification period, but not for the entire certification period, set a review about the time of the expected change to do a new best estimate of income. For example, if someone will receive 14 weeks of unemployment during the certification period, schedule a review to occur just before the end date of the income and do a new best estimate based on the client's current circumstances at that time.
Expected changes: If a change is expected but not certain, such as income from a seasonal job, set a shorter review period to check on the expected change. Do a new best estimate based on the actual change.
Factoring Income: Non-MAGI-Based Family, Pregnant Women and Child
Factor income received weekly or every two weeks. First determine the most accurate best estimate of income a client receives each pay period.
To factor weekly income, multiply the weekly best estimate amount by 4.3 to determine a monthly amount.
When income is received every two weeks, multiply the two-week best estimate by 2.15 to determine a monthly rate.
Do not factor income for Retroactive Medicaid months. See section 445-2 to determine what income to count for the retroactive month.
Do not factor income for Aged, Blind or Disabled Medicaid programs, or MAGI-based coverage groups.
Do not factor new income in months when the client does not receive the full number of paychecks for that month.
Do not factor terminated income.
Best Estimate for Aged, Blind and Disabled Medicaid, and Long-Term Care Groups
Use the same prospective budgeting process for aged, blind and disabled categories (generally referred to as Disabled Medicaid) and Long-term Care/Waiver groups as you would for any other Medicaid program. The only difference requires you to count actual monthly income received, or expected to be received, rather than factoring the income. Count the third or fifth paycheck in the month received to determine Medicaid eligibility for aged, blind and disabled Medicaid cases for such months. If changes are expected in the future, control for those changes through the review process.
Self-employment income can be annualized for aged, blind and disabled cases.
For Waiver Medicaid Programs, if the client's statement of total earned income is below $65 per month, waive the requirement to request verification of actual income from the client when electronic match data is unavailable, and there is no other information that indicates the client statement is incorrect.
Documentation and Changes
Document the method of determining the best estimate.
Refer to Section 815-5 when a change has occurred that results in the best estimate needing to be changed. For residents of nursing homes, Utah State Hospital, and Utah Developmental Center follow the policy in 833.